Jerome Lyn-Sue

Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos)

BACKGROUND Multiple studies have demonstrated the feasibility of natural orifice transluminal endoscopic surgery in animal models. OBJECTIVE To determine the feasibility of transgastric peritoneoscopy and liver biopsy in human beings. SETTING Our institutional review board approved the procedures in the operating room with the patients under general anesthesia. DESIGN AND INTERVENTIONS During laparoscopic gastric bypass surgery a flexible endoscope was introduced into the peritoneal cavity through the gastric-wall incision. A peritoneoscopy with a liver biopsy was performed, then the flexible endoscope was withdrawn into the stomach, and gastric bypass surgery was completed laparoscopically. PATIENTS Three patients who were morbidly obese (mean weight 115.22 +/- 9.07 kg [254 +/- 20 lb]). MAIN OUTCOME MEASUREMENTS The ability to navigate a flexible endoscope inside the peritoneal cavity, to visualize the intra-abdominal organs, and to perform a liver biopsy without laparoscopic assistance. RESULTS It was very easy to navigate the flexible endoscope inside the abdomen by using torque, advancement, and withdrawal of the endoscopic shaft, as well as by movement of the endoscope tip. The flexible endoscope provided an excellent view and adequate illumination of the peritoneal cavity. The orientation of the flexible endoscope inside the peritoneal cavity was technically easy, even in the retroflex position. Systematic visualization of the liver, the spleen, the omentum, and the small and large intestine was easily achieved through the flexible endoscope without laparoscopic assistance. A liver biopsy was successfully completed in all cases by obtaining adequate tissue samples for histologic examination. LIMITATION This was a pilot feasibility study. CONCLUSIONS Transgastric flexible endoscopic peritoneoscopy in human beings is technically feasible, simple, and can become a valuable tool that complements and facilitates laparoscopic interventions inside the peritoneal cavity.

Looking Beyond Age and Co-morbidities as Predictors of Outcomes in Paraesophageal Hernia Repair

IntroductionParaesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes.MethodsWe performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001–2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary, and thromboembolic events, (VTE)).ResultsOf the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients, while adjustment for cardiac complications or pneumothorax did not eliminate the difference.ConclusionsWhile PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events.

Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management

BACKGROUND Sleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%-7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL. METHODS A retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting. RESULTS One hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1-7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15-56). Mean hospital length of stay was 30 days (range 20-42). CONCLUSION SLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.

Intraoperative Considerations for Robotic Repair

Much like laparoscopic hernioplasty, the keys to performing a successful robotic hernia repair lie as much in the attention to ancillary details of the procedure as they do in performing the actual operative steps. Seemingly mundane details like room setup, patient positioning, port placement, and instrumentation all ultimately facilitate the successful completion of the robotic-assisted case. In this chapter we will discuss intraoperative considerations for robotic hernia repair including a review of the technical aspects of the procedures and will provide details and helpful tips for managing difficulties unique to robotic-assisted hernia repair. As of the writing of this chapter, the da Vinci system is the only device available in the United States for hernia repair and our discussion will focus entirely on this system.